0
Crisis Intervention
Strategies for Suicidal
Adolescent and Adult
Patients
41st Advanced International Winter Symposium
Addictive Disorders, Behavioral Health
and Mental Health
January 25-28, 2015
Barry J. Koch Ph.D.
barryjkoch@gmail.com
1
Contents
Page
Statistics
2
National Suicide Statistics (American Association of Suicidology)
4
Suicide Rates by State (American Association of Suicidology)
5
Suicide in Colorado (The Colorado Trust – 2002 and 2008)
9
Suicide Deaths by County (Colorado Department of Public Health and Environment - thru 2013
11
Suicide in El Paso County (2009 report sponsored by Aspen Pointe and Suicide Prevention Partnership - by
Rhonda D. Terry Ph.D. and Annette D. Fryman, RN, MBA)
14
The current suicide problem in El Paso County - Summary of the last 6 years (2008-2013)
16
Military and Suicide (Matt Reid, Chief Deputy, El Paso County Coroner’s Office)
Presentation contents
17
24-hour crisis hotline services (Rocky Mountain Crisis Partners)
18
Working on crisis hotlines (Diane Ackerman)
20
Key crisis intervention principles in working with suicidal patients
21
Illustrative quotes
23
Counseling principles condensed
24
Vocabulary of Feelings
25
What a suicidal person may feel or experience
26
Adolescent suicide
28
Continuum of negative thought patterns - thoughts that lead to suicide (The Glendon Association)
29
The three key components of completed suicide (Thomas Joiner)
31
Can suicidal thinking be addictive? (Ken Tullis)
32
Indicators of lethality
33
Suicide risk assessment
34
Assessment questions /protective factors (Suicide Prevention Resource Center)
35
System management of a suicidal patient
36
Suicide safety contracts
37
Chart documentation / Risk management
2
National Suicide Stats - 2011
(from American Association of Suicidology)



Total number of suicides in the US had been steady over decades (roughly 30,000 per year), though it has
increased for 6 years in a row since 2005 (32,637 ->33,300 -> 34,598 -> 36,035 ->36,909 -> 38,364->39,518).
The average over the last 7 years has been of 35,909 from 2005-2011)
805,286 suicides in the 25 years from 1987 to 2011 (average of 32,211 per year)
The 1990’s

rates declined in the 90’s for essentially all groups
o 1995: 31,284 – rate of 11.9
o 1996: 30,903 – rate of 11.6
o 1997: 30,535 – rate of 11.4
o 1998: 30.575 – rate of 11.3
o 1999: 29,199 – rate of 10.7




306,940 suicides in the 90’s
7,673,500 attempts in the 90’s
1,841,640 survivors in the 90’s
1,867,890 suicides in the 20th century
2011 Statistics
Completions (Fatal Outcomes)
 Total number: 39,518 (108.3 per day) – up from 89.4 per day in 2005
 Rate: 12.7 per 100,000 population (1.6% of all deaths)
 Average of one person every 13.3 minutes killed themselves
 10th ranking cause of death in the US (homicide is 16th); 2nd ranking cause of death for young people
(behind accidents)
 287 children below age 15 died by suicide in 2011 in the US, up from 180 in 2007
 3.6 male deaths by suicide for each female death by suicide
Attempts
 987,950 annual attempts in the US; (up from 765,000 in 2001)
 One attempt every 32 seconds
 25 attempts for every death by suicide
 3 female attempts for each male attempt
 Attempts are most common among the young (young: 100-200 attempts to 1 suicide; old: 4 attempts to 1
suicide)
 For every suicide death… there are 5 hospitalizations and 22 emergency department visits for suicidal
behavior; over 670,000 visits per year
Age
 Young:
o Average of one young person every 1 hour and 49 minutes killed themselves (if the 287 suicides
below age 15 are included, one young person every 1 hour and 43 minutes)
o 2nd ranking cause of death for young people
o Young were 14.1% of 2011 population and comprised 12.2% of the suicides
o 4,822 total suicides among young people ages 15-24
o 287 suicides in the US among children ages 10-14
 Old:
o Average of 1 old person every 1 hour and 23 minutes died by suicide
o Old made up 13.3% of 2011 population but represented 16.0% of the suicides.
3

Suicide rates by age (2011)
5-14
0.7
15-24
11.0
25-34
14.6
35-44
16.2
45-54
19.8
55-64
17.1
65-74
14.1
75-84
16.5
85+
16.9
65+
15.3
Total
12.7
Gender
 Total number of suicides (2011)
Men
31,003 (84.9 per day)
Women 8,515 (20.2 per day)
 3.6 male deaths by suicide for each female death by suicide
 Suicide rates by gender (2011)
Men
20.2
Women 5.4
Survivors
 Defined as someone who has lost a loved one to death by suicide
 Estimated that each suicide intimately affects at least 6 other people
 Estimates that there are 4.8 million survivors in the USA population, 1 in every 64 Americans (based on
805,286 suicides in the last 25 years X 6 survivors per suicide)
 With one suicide every 13.3 minutes, there are 6 new survivors each 13.3 minutes as well
 The number of survivors grew by at least 237,108 in 2011
Suicide Methods
Method
Firearm suicides
All but firearms
Suffocation/hanging
Poisoning
Cut/pierce
Drowning
Number
19,990
19,582
9,913
6,564
660
354
Rate
6.4
6.3
3.2
2.1
0.2
0.1
Percent of Total
50.6%
49.4%
25.1%
16.6%
1.7%
0.9%
Years of Potential Life Lost


1,142,673 years of potential life lost before age 75 (36,366 of 39,518 suicides were below age 75)
Middle aged were 26.6% of the 2011 population but were 38.9% of the suicides
4
Suicide Rates by State
(Source: American Association of Suicidology)
2008
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
Alaska
Wyoming
New Mexico
Montana
Nevada
Idaho
Colorado
Oklahoma
Arkansas
Tennessee
South Dakota
Vermont
Oregon
Arizona
Florida
West Virginia
Utah
Kentucky
Mississippi
Maine
N. Hampshire
Washington
North Dakota
Wisconsin
Missouri
Alabama
Iowa
Indiana
North Carolina
South Carolina
Delaware
Ohio
Pennsylvania
Virginia
Kansas
Louisiana
Michigan
Minnesota
Nebraska
Texas
Rhode Island
Hawaii
California
Georgia
Illinois
Connecticut
Maryland
Massachusetts
DC
New York
New Jersey
USA total:
2009
Rate
24.6
23.3
21.1
21.0
20.2
16.5
16.3
15.8
15.6
15.6
15.4
15.1
15.1
15.0
14.9
14.4
14.3
14.3
13.9
13.7
13.5
13.5
13.4
13.2
13.1
12.9
12.7
12.7
12.6
12.6
12.4
12.3
12.3
12.2
12.1
12.0
11.8
11.4
10.7
10.5
10.4
10.3
10.3
10.1
9.3
9.0
9.0
7.8
7.3
7.2
7.1
11.8
No.
169
124
419
203
528
252
803
575
447
973
124
94
572
972
2740
261
390
612
409
181
179
889
86
743
779
604
380
809
1162
565
109
1412
1539
948
337
532
1180
596
191
2552
110
133
3775
981
1198
315
507
509
43
1409
615
36,035
Montana
Alaska
Wyoming
Idaho
Nevada
New Mexico
Colorado
Oregon
Arizona
Utah
South Dakota
Oklahoma
Florida
Tennessee
Maine
Arkansas
Missouri
Alabama
Vermont
West Virginia
North Dakota
Washington
Kentucky
Kansas
South Carolina
Hawaii
Mississippi
Indiana
Pennsylvania
Wisconsin
N. Hampshire
North Carolina
Virginia
Delaware
Iowa
Michigan
Georgia
Texas
Rhode Island
Minnesota
Louisiana
California
Ohio
Maryland
Nebraska
Illinois
Connecticut
Massachusetts
New York
New Jersey
DC
USA total:
Rate
22.5
20.5
20.4
19.7
19.1
18.7
18.7
16.8
16.1
16.1
15.9
15.4
15.4
15.0
14.9
14.6
14.4
14.3
14.0
13.9
13.9
13.8
13.8
13.7
13.6
13.6
13.5
12.9
12.9
12.8
12.5
12.5
12.2
12.1
12.0
11.7
11.5
11.3
11.2
11.1
10.9
10.3
10.2
9.7
9.5
9.1
9.0
8.0
7.3
6.4
4.8
12.0
No.
219
143
111
304
505
376
941
644
1060
449
129
567
2858
947
197
422
860
673
87
253
90
921
592
382
619
175
381
828
1631
724
166
1174
963
107
361
1169
1134
2809
118
584
490
3823
1176
551
170
1177
316
530
1417
557
29
36,909
Wyoming
Alaska
Montana
Nevada
New Mexico
Idaho
Oregon
Colorado
South Dakota
Utah
Arizona
Vermont
Oklahoma
North Dakota
Arkansas
Hawaii
West Virginia
N. Hampshire
Tennessee
Florida
Kentucky
Missouri
Washington
Alabama
Kansas
Maine
Wisconsin
South Carolina
Indiana
Mississippi
Michigan
Ohio
Pennsylvania
North Carolina
Louisiana
Rhode Island
Iowa
Virginia
Delaware
Georgia
Texas
Minnesota
Nebraska
California
Connecticut
Illinois
Massachusetts
Maryland
New Jersey
New York
DC
USA total:
2010
Rate
23.2
23.1
22.9
20.3
20.1
18.5
17.9
17.2
17.2
17.1
17.1
16.9
16.5
15.8
15.3
15.2
15.1
14.9
14.9
14.8
14.5
14.3
14.2
14.2
14.1
14.0
13.9
13.8
13.3
13.1
12.8
12.5
12.4
12.3
12.3
12.3
12.2
12.0
11.8
11.7
11.5
11.4
10.6
10.5
9.9
9.2
9.1
8.7
8.2
8.0
6.8
12.4
2011
No.
131
164
227
547
413
290
685
865
140
473
1093
106
618
106
447
207
279
196
943
2789
631
856
957
679
401
186
793
637
864
388
1263
1439
1576
1174
557
129
372
963
106
1133
2891
606
193
3913
353
1178
598
502
719
1547
41
38,364
Wyoming
Montana
New Mexico
Alaska
Vermont
Nevada
Oklahoma
Arizona
Colorado
Utah
Idaho
Maine
Oregon
West Virginia
Arkansas
South Dakota
Missouri
North Dakota
Kentucky
Florida
New Hampshire
Washington
Tennessee
South Carolina
Iowa
Kansas
Pennsylvania
Alabama
Indiana
Hawaii
Mississippi
Wisconsin
Virginia
Minnesota
Ohio
North Carolina
Louisiana
Michigan
Georgia
Delaware
Texas
California
Nebraska
Connecticut
Rhode Island
Maryland
Illinois
Massachusetts
New York
New Jersey
DC
USA total:
Rate
23.3
23.3
20.2
19.8
19.2
19.0
18.3
17.9
17.8
17.8
17.7
17.7
17.0
16.5
15.7
15.5
15.5
15.5
15.5
15.1
15.0
15.0
14.9
14.1
13.8
13.7
13.7
13.6
13.5
13.1
13.1
13.1
13.0
12.8
12.7
12.6
12.5
12.4
11.8
11.6
11.3
10.6
10.5
10.3
9.6
9.6
9.5
8.9
8.5
7.8
6.0
12.7
No.
132
232
420
143
120
516
693
1160
913
502
281
235
656
306
462
128
933
106
675
2880
198
1021
955
658
422
394
1747
654
881
181
389
745
1054
683
1465
1213
573
1221
1157
105
2896
3996
193
370
101
558
1226
585
1658
689
37
39,518
5
Suicide in Colorado
Source: The Colorado Trust – 2002 and 2008
Coloradans are at particularly high risk of suicide
 Colorado’s suicide rate ranked 9th highest in the US in 2006 (down from 6th in 2005)
 Suicide rates are higher in Western mountain states:
o There are no definitive research findings that explain the higher rates of suicide in Western mountain states
o Possible explanations include lower population density, high rates of gun ownership, higher levels of
stigma about the use of mental health services, and less availability of mental health services
 Colorado suicide rates have exceeded the national average by almost 40% since 1910
 9th leading cause of death in Colorado
 2nd leading cause of death for Coloradans age 10-34
 In 2007, more Coloradans died by suicide (805) than in motor vehicle accidents or from illnesses
 600 suicide deaths per year; 9600 attempts per year (16 attempts per every death by suicide)
 On average 2,838 Coloradans are hospitalized per year because of suicide attempts
 For the years 1999-2007, the average suicide rate in Colorado was 15.7, and ranges across the counties from
7.2 to 42.1 per 100,000 population
 Four Colorado counties are above the Colorado mean suicide rate: Moffat, Mesa, Fremont, and Pueblo
 The greatest number of deaths by suicide each year occur in metropolitan Denver area counties
 Existing resources are inadequate to address the problem
 Recommended strategies to address the problem:
o Greater public awareness
o More widespread suicide training
o Better links among service providers – need to be inclusive of a broad array of stakeholders
El Paso County
 From 1990-2007 El Paso County had the highest suicide rate for youth under age 18 of all counties in
Colorado (97 per 100,000 population)
 El Paso County reports approximately 70 suicide deaths each year
Economic Impact of Suicide
 Suicide cost the US economy $125 billion in 2000
 Suicidal behavior
 2002 data shows direct costs in Colorado (health care expenses associated with autopsies or criminal
investigations) to be $59 million, while indirect costs in Colorado (estimates of productive life lost – assuming
employment until age 65) were $571 million; 2008 data shows the combined direct and indirect economic
burden to the state of Colorado to be more than $1 billion annually
 Each attempt costs $31,000 in indirect costs
 Each completed suicide costs $446,000 in indirect costs
National and State Responses
 Surgeon General’s Report of 1999 recommends that a wide variety of public and private sector organizations
coordinate efforts toward comprehensive suicide prevention plans
 In 1998 the Suicide Prevention Advisory Board was established, which led in 1999 to creation of the Office of
Suicide Prevention within the Colorado Department of Public Health and Environment
Who is at risk for suicide in Colorado?
 The vast majority of people who die by suicide do so in their first attempt, and give no indication of intent
before doing so (but in what appears to be conflicting data, it is also true that 4 out of 5 people who commit
suicide have tried to warn others of their intent)
 The largest number of suicide deaths occur among men ages 35-44; women are more likely to attempt
 56% of males in Colorado who die by suicide use a firearm (33% of women)
6











Suicide rate is highest for men 75 years and older (4 times the statewide average); in the next decade the
number of Coloradans 65 and older will increase by 96%
Suicide is the 2nd leading cause of death among teenagers and young adults in Colorado; no change in rate
(8.4) since 2000 for ages 15-19; rate for ages 20-24 is 17.8, compared to the national average for this group of
12.3; in 45% of deaths by suicide among 20-24 year olds, there was evidence of a problem with an intimate
partner
Young people are much more likely to be hospitalized for a suicide attempt than older age groups
In 2005, Colorado 10% of high school students reported having made a suicide plan, 6.7% reported
having attempted suicide, and 1% reported having received medical treatment following a suicide
attempt
Nearly half of Colorado teenagers who died by suicide had experienced a personal crisis within the two weeks
prior to their death
Whites have the highest rate of death by suicide (17.4 per 100,000 population), compared to American Indian
(12.7); African American (10.1); Hispanic/ Latino (9.7); and Asian (9.0)
The rate among Colorado’s Hispanic/Latino population is almost twice the suicide rate of the US
Hispanic/Latino population (5.79)
Three factors are strongly related to the rate of death by suicide:
o 1) Higher levels of unemployment
o 2) Higher proportions of people living in social isolation
o 3) Lower proportions of Hispanic/Latino residents whose cultural norms may serve as a protective factor
against suicidal behavior
16 factors most directly connected to suicide risk:
o Mental illness, particularly mood disorders (depression), schizophrenia, anxiety disorders, and personality
disorders
o Alcoholism / drug abuse
o Prior suicide attempts
o Easy access to lethal means
o Lack of social support; isolation, living alone
o Hopelessness
o Being an older, white male
o History of suicide in the family; exposure to and influence of others who have died by suicide
o Work problems / unemployment
o Relational or social loss
o History of trauma or abuse
o Anger, aggression, impulsivity
o Physical illness
o Local clusters of suicides that ha a contagious influence on others’ plans
o Stigma associated with seeking help
o Barriers to accessing health and mental health care
Military veterans, the elderly, and sexual-minority individuals have been identified as at particularly
high risk for suicide
Risk among military:
o There are more than 425,000 US Armed Services veterans living in Colorado
o There are no data about the rate of death by suicide among discharged members of the US Armed Forces
in Colorado
o Multiple risk factors include:
 Male gender
 Elderly
 Diminished social support
 Medical and psychiatric conditions associated with suicide
 Knowledge of and access to lethal means
 Combination of PTSD and TBI may make treatment difficult and the risk of suicide higher
7

Risk among sexual minorities:
o 44% of sexual minority reported having attempted suicide, compared to 13.5% of their heterosexual
counterparts
o Risk factors among adolescent sexual minorities include: hopelessness, victimization by bullies, meth use,
and homelessness
Protective factors
 Medications for mental health disorders
 Easy access to effective clinical care
 Support for seeking help
 Restricted access to lethal means of suicide
 Strong connections to family, health professionals, and community
 Skills in problem solving and conflict resolution
 Cultural and religious beliefs that discourage suicide
Access / Barriers to Suicide-Related Services
 Only 50% of individuals with suicidal intent have sought any type of professional help in the past year
 Most common reasons for not seeking help:
o 81% wanted to solve the problem on their own
o 62% thought the problem would get better by itself
o 62% thought getting help was too expensive
o 57% were unsure where to go for help
o 52% thought help would probably not do any good
o 43% thought it would take too much time or be inconvenient
o 38% thought health insurance would not cover treatment
o 33% went in the past, but it did not help
o 29% would feel embarrassed if friends knew they were seeking professional help
o 19% were scared about being put into the hospital against their will
o 19% were not satisfied with available services
o 10% could not get an appointment
o 5% had a language problem
Existing Resources
 Access to mental health care varies and is often limited for low-income Coloradans
 Shrinking public resources
 Current suicide-related resources in Colorado are insufficient to meet the needs of state residents:
o More than half of Colorado counties are designated by the federal government as “manpower
shortage areas” for psychiatrists and other mental health professionals
o Large number of unmet mental health needs
o Lack of funding for services (the largest barrier to expansion of services) - Colorado’s per capita
expenditures for mental health care are well below most states ($74 compared to national average of
$100); as a result waiting lists are common
 239 suicide resources in Colorado
 Colorado is divided into 17 public mental health service areas
 All public mental health clients are assessed for suicide risk
 Most common services
o Crisis treatment
o Screening / referral
o Ongoing mental health treatment
 Services most effective include:
o Assessment of mental status
o Crisis intervention
o 24-hour access
8
Components of a Suicide Prevention System
 Determine who needs services and who can provide them
 Types of services needed:
o Screening, assessment, and referral
o Gatekeeper training
o Crisis treatment
o Crisis hotlines
o Mental health treatment
o Suicide support programs
o Community education
o Restricting access to lethal means
 Community partners needed (must work together to create a continuum of services that responds quickly and
efficiently):
o Primary care setting
o Schools
o Senior centers
o Mental health
o Substance abuse centers
o Community support groups
o Faith community
Strategies to Combat the Problem
 Encourage at-risk individuals to seek care
o Increase public awareness of suicide
o Develop community-based prevention programs
o Improve primary-care providers’ ability to detect, treat and refer suicidal patients
o Create suicide prevention programs in schools
o Expand gatekeeper training (friend, teacher, police officer, clergy, family member, etc.)
o Provide services to people experiencing traumatic events
 Improve care for at-risk individuals
o Refine and distribute screening assessment tools
o Expand professional training on suicide prevention
o Expand access to mental health care
o Improve the ability of mental health providers to address suicide
o Provide support for suicide survivors
o Encourage culturally competent approaches
 Promote policies to help reduce the risk of suicide
o Improve financing for mental health services (mental health parity legislation)
o Reduce access to firearms
o Promote mental health literacy
o Promote mobile mental health clinics
 Develop the full potential of the Colorado Office of Suicide Prevention (OSP)
9
Suicide Deaths in Colorado by County (64 total counties)
Source: Colorado Department of Public Health and Environment, Death Statistics
2008-2013



The population of 80% of the state of Colorado lives in 9 counties (all with populations of 269,000 or more)
Of those 9 counties, El Paso County had the highest rate of suicide (23.3)
El Paso County had 30% more suicides (878) than the next largest amounts in counties of comparable
size (Jefferson County had 622 suicides; Denver County had 601, Arapahoe County had 582)
El Paso
Jefferson
Denver
Arapahoe
Adams
Boulder
Larimer
Douglas
Mesa
Weld
Pueblo
Fremont
Garfield
La Plata
Broomfield
Montrose
Montezuma
Teller
Eagle
Delta
Routt
Park
Alamosa
Summit
Elbert
Moffat
Chaffee
Morgan
Pitkin
Las Animas
Grand
Otero
Logan
Archuleta
Rio Grande
Huerfano
Clear Creek
Conejos
Gunnison
Prowers
Population
2013
655,811
552,212
648,926
606,617
468,686
309,875
315,730
306,032
147,811
269,640
161,260
46,262
57,298
53,447
59,452
40,752
25,648
23,279
52,338
30,299
23,400
16,192
15,805
28,638
23,680
13,090
18,283
*
17,376
14,361
14,287
*
21,857
12,168
11,736
*
*
8,228
15,455
12,236
Population
(total 2008-2013)
3,774,300
3,236,812
3,687,161
3,484,818
2,685,220
1,796,226
1,821,691
1,742,762
875,059
1,539,000
955,498
280,796
336,116
310.019
340,745
244,176
152,600
139,667
309,714
182,921
139,462
96,877
93,281
168,009
138,969
80,459
107,244
169,017
102,582
90,724
86,962
112,633
133,267
72,273
71,636
40,575
54,543
49,653
91,963
74,824
2008
2009
2010
2011
2012
2013
Total
Rate
(6 yrs)
138
89
94
87
68
46
37
33
35
28
21
20
11
9
7
6
7
3
9
6
9
6
*
3
6
3
3
4
5
*
*
3
3
*
3
3
*
*
3
*
172
99
101
100
73
59
58
34
32
30
36
17
12
9
8
11
6
7
9
7
5
7
4
5
5
5
4
*
3
6
*
3
*
7
*
*
3
4
3
4
155
116
101
72
52
61
45
35
30
42
29
13
7
10
11
8
9
11
5
4
11
7
6
*
4
6
6
3
6
5
*
5
5
*
*
4
5
3
*
*
112
100
95
105
65
53
54
46
49
35
36
7
12
9
11
8
7
8
5
9
5
4
3
6
3
5
4
6
6
*
4
3
4
*
*
*
3
*
*
*
151
127
115
105
85
59
70
45
51
41
29
8
10
16
11
10
9
5
9
4
8
5
6
4
6
3
4
7
*
3
4
3
*
3
3
3
*
*
3
*
150
91
95
113
70
56
56
61
28
48
32
21
13
9
6
7
11
9
7
12
4
6
8
9
4
4
3
*
4
6
7
*
4
5
5
*
*
4
3
4
878
622
601
582
414
334
320
254
225
224
183
86
65
62
54
50
49
43
44
42
42
35
29
29
28
26
24
24
24
22
20
19
19
18
16
15
14
14
13
13
23.3
19.2
16.3
16.7
15.4
18.6
17.6
14.6
25.7
14.6
19.2
30.6
19.3
20.0
15.8
20.5
32.1
30.8
14.2
23.0
30.1
36.1
31.1
17.3
20.1
32.3
22.4
14.2
23.4
24.2
23.0
16.9
14.3
24.9
22.3
37.0
25.7
28.2
14.1
17.4
10
Lake
Saguache
Kit Carson
Rio Blanco
San Miguel
Yuma
Baca
Bent
Crowley
Gilpin
Washington
Sedgwick
Custer
Dolores
Lincoln
Costilla
Ouray
Cheyenne
Phillips
Kiowa
Hinsdale
Jackson
Mineral
San Juan
Total
Population
2013
7,308
6,229
8,052
*
*
10,114
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
5,264,894
Population
(total 2008-2013)
43,705
37,240
48,928
39,435
44,657
60,291
22,715
36,730
33,896
32,475
28,684
14,235
25,316
12,205
32,719
21,358
26,674
11,198
*
*
*
*
*
*
30,499,274
2008
2009
2010
2011
2012
2013
Total
Rate
(6 yrs)
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
801
*
3
*
*
*
*
*
4
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
940
3
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
867
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
910
*
*
*
*
*
*
*
*
*
*
*
3
*
*
*
*
*
*
*
*
*
*
*
*
1.053
3
3
3
*
*
3
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
1,004
12
10
10
7
7
7
7
6
5
5
5
4
4
4
4
4
3
3
------------------5,575
27.5
26.9
20.4
17.8
15.7
11.6
30.8
16.3
14.8
15.4
17.4
28.1
15.8
32.8
12.2
18.7
11.2
26.8
------------------18.3
* Cells that have an asterisk are years in which there are less than three suicides in the county. The use of asterisks
allows for confidentiality when the numbers are very small.
11
El Paso County Suicide Rates: Cause For Alarm?
Rhonda D. Terry Ph.D. & Annette D. Fryman, RN, MBA
May 20, 2009
In the Pikes Peak United Way-sponsored 2008 Quality of Life Indicators report, high suicide rates for teens
and older adults were identified among the four significant health issues for this region. They were the only health
issues out of the four to receive red flag warnings. This study prompted Pikes Peak Behavioral Health Group (now
Aspen Pointe) and Pikes Peak Suicide Prevention Partnership to investigate suicides in El Paso County.
Summary
 Colorado has one of the highest suicide rates in the nation. Although the ranking varies from year to year, it
remains consistently in the top ten. All of the Rocky Mountain States and Alaska lead the nation in deaths by
suicide. And yet, there is very little evidence regarding reasons for the high suicide rate in Colorado and
other western states.
 According to the Colorado Office of Suicide Prevention, there are a number of theories for why suicide rates
are higher in this part of the country:
o One hypothesis is the "frontier mentality" - that the west tends to attract people who are independent and
subscribe to the "just pick yourself up by your boot straps and handle it yourself” mindset.
o People who relocate to the west often are geographically removed from extended family and friends, losing
their natural support systems.
o It is also possible that there is a stronger stigma in the west attached to asking for help and receiving
treatment for mental health disorders like depression.
o Access to treatment in the western states can be difficult due to limited mental health funding and the
challenges presented to people who live in rural areas where there are relatively few treatment providers.
 In 2007, suicide was the 7th leading cause of death for both Colorado and El Paso County.
 In all years but one spanning 2000-2007, annual suicide rates for El Paso County equaled or surpassed
the rates for Colorado. El Paso County has slightly higher suicide rates than Colorado for specific
demographic groups - such as males ages 25-54, whites, and Hispanics.
Comparison of Suicide Rates in El Paso County, Colorado, and the US
 Colorado and El Paso County rates are notably higher than for the nation
 Colorado’s rate is consistently among the top 10 in the nation
 The 2000-2007 El Paso County annual suicide rates have equaled or surpassed the rates for Colorado in all
years except one (2006)
Suicide Rates by Area in El Paso County
 An analysis of suicide rate by zip codes in El Paso County reveals that the highest suicide rates are in the
central metro or downtown Colorado Springs area. The following zip codes are above national average and
above El Paso County average (80903, 80904, 80905, 80907, 80909, 80910, 80917)
 Zip codes 80904 and 80905 (West central metro Colorado Springs) have the highest rate (27.12 per 100,000
population)
Examination of the Suicide Rate for the Colorado Springs Metropolitan Area
 In 2004, the metropolitan area of Colorado Springs had the second-highest suicide rate in the nation (26.1
suicides per 100,000 residents) compared with 53 other large cities (Las Vegas had the highest rate).
 Over a 15-year span, Colorado Springs' suicide rate averaged 19.1 suicides per 100,000 residents.
Suicide Rates by Age and Gender
 From 2000-2005 the average rate for males in El Paso County is about 3.5 times higher than the rate for females
(consistent with national trends)
 Both male and female average rates for 2000-2005 are higher for Colorado and El Paso County than for the
nation
 Rates from 2000-2005 are higher for all age groups compared to national figures
12
Teen Suicide
 For the US, Colorado, and El Paso County suicides among 12-19 year olds account for 6-7% of total suicides
 The rates for 12-19 year olds in Colorado (8.7) and El Paso County (9.2) are notably higher than the national
rate (5.5)
Suicide Among Older Adults
 Suicides rates among older adults in Colorado (18.1) and El Paso County (18.9) are notably higher than the
national rate (12.8)
 This population is growing as a percentage of Colorado and county population
Suicide Rates for Ethnic and Racial Groups
 Average 2000-2005 suicide rates for White individuals in El Paso County (19.2) exceed US (11.8) and
Colorado (16.8) rates
 Average 2000-2005 suicide rates for Hispanic individuals in El Paso County (13.1) exceed US (5.7) and
Colorado (9.4) rates
 Suicide rates for El Paso County Black individuals are slightly less than rates for the US, but are similar to
Colorado rates
The Prevalence of Suicide Risk Factors among El Paso County Citizens
 Depression, and other behavioral health problems:
o Colorado ranked first in the nation in the rate of adolescents 12-17 who reported having at least one
major depressive episode during the previous year. Almost 10% of Colorado youth reported having
such an episode, defined as a period of at least two weeks in which they had most of the signs of clinical
depression
 Substance abuse:
o Compared to youth from other states, Colorado adolescents ages 12-17 ranked fourth in alcohol
dependence and sixth in dependence on or abuse of illegal drugs
 Prior suicide attempts:
o Nonfatal attempts are more common among women and youth compared with men and the elderly
o In the US, Colorado, and El Paso County about 60% of hospitalized suicide attempt patients are female
o El Paso County rates of hospitalizations for injuries classified as suicide have surpassed Colorado
rates recently (see below)
Colorado
El Paso County

2000
55.6
44.4
2001
58.3
50.2
2002
56.1
51.4
2003
55.6
56.8
2004
58.0
57.0
2005
66.4
70.4
2006
56.4
66.8
Easy access to firearms:
o For El Paso County males, the percent of suicides by firearms is approximately the same as the percentages
for Colorado and the nation
o For El Paso County females in 4 of 6 age groups, the percentage of suicides by firearms is slightly higher
than Colorado percentages, but very similar to national percentages
Method of Suicide Attempt for Hospitalized Individuals
 Among El Paso County citizens hospitalized for a suicide attempt, the primary means of injury is drug
overdose (79%), followed by cutting/piercing (14%), inhaling vehicle exhaust/gas (3%), hanging/suffocation
(2%), firearms (2%), and jumping (1%). Nationally, 51% of completed suicides use firearms.
 From 2002-2006, 1,689 El Paso County citizens were hospitalized for reasons categorized as suicide
attempts (338 per year); of these, 2-3% died before discharge
 The percentages for suicide attempt methods for El Paso County mirror almost exactly those for the state of
Colorado
13
Method of Suicide for Suicide Death Investigated by El Paso County Coroner: 2005-2007
 The most common method of suicide occurring in El Paso County was firearms/gunshot wounds, most
commonly to the head (54%), followed by hanging/suffocation (22%), drug overdose/poison (14%), inhaling
vehicle exhaust/gas (9%), cutting/piercing (1%), and jumping/drowning (1%).
Veterans
 A portion of the excess suicide rate in El Paso County may be due to the high proportion of veterans in
the population.
 Veterans comprise approximately 18% of the Colorado Springs adult population (more than any county
in Colorado), second among metropolitan areas only to Virginia Beach, VA
 The suicide rate for veterans in El Paso County (39.3) is slightly lower than the rate for veterans in Colorado
(41.8), both of which are much higher than the national rate for veterans (19.7)
 From 2004-2007 veterans accounted for almost one-third of the total suicides in El Paso County (31.1%),
compared to one-fourth (23.3%) in Colorado
 In El Paso County and in Colorado, rates are higher among younger and older veterans, compared with middleaged veterans
 For the 65 and older age group, veterans accounted for over two-thirds of the suicide deaths in El Paso County
The Economic Cost of Suicide and Suicide Attempts in El Paso County: 2004-2006
 Completed suicides:
o The estimated cost to the community of the 296 suicide deaths was approximately $143 million per year,
or $1.45 million per suicide
o The medical costs associated with El Paso County completed suicides is about $4 million annually, or
$3,600 per completed suicide
 Attempts:
o From 2004-2006: 1,100 hospitalizations for attempted suicides were recorded for El Paso County residents
o Total costs to El Paso County were approximately $9.25 million per year ($5.5 million cost of lost
work, plus $3.75 million in medical costs), or $25,000 per attempt.
Conclusions
The facts regarding suicide in El Paso County contained in this report show that suicide is a significant
health problem for our area:






Suicide rates generally equal or slightly surpass Colorado rates.
Suicide is the 7th leading cause of death.
Medical costs are approximately $4 million annually.
Suicide rates are higher than Colorado in specific populations like males ages 25-54, whites, and Hispanics.
Veterans account for almost one-third of the total suicides.
Suicide rates vary by county location; for example, the suicide rate in west central metro Colorado Springs area
is 27.20 compared to the El Paso County average of 16.91.
At the same time, the 2007 report from the National Association of County and City Health Officials
indicating that Colorado Springs had the second highest suicide rate in the country does not hold true when rates are
examined over several years rather than a single year. El Paso County's suicide rate (16.91) is more than 50% higher
than the suicide rate for the rest of the country (10.80). But for the most part, El Paso County mirrors the suicide
rates of Colorado and other Western states.
In 2001, the U.S. Surgeon General called for communities across the nation to institute broad-scale,
comprehensive strategies to prevent suicide. One of the suggested approaches was increased public awareness and
education. We are hopeful that this paper and Community Forum serve this purpose.
So, is El Paso County's suicide rate a cause for alarm?
We should not be fearful about suicide - but we do need to take action. Suicide is a tragic, devastating and
costly event that may be largely preventable.
14
The Current Suicide Problem in El Paso County
Summary 2008-2013
Year
2008
2009
2010
2011
2012
2013









US
(rate per 100,000
population)
11.5
12.0
12.4
12.7
not available yet
not available yet
Colorado
(rate per 100,000
population)
16.1
18.7
16.6
17.8
20.3
19.1
El Paso County
(rate per 100,000
population)
23.0
28.2
24.7
17.6
23.4
22.9
# of suicides in El
Paso County
138
172
155
112
151
150
In 5 of the 6 years from 2008-2013, El Paso County has had a higher rate of suicide than both the state of
Colorado and the United States (only in 2011 was the El Paso County rate slightly below the rate for the state
of Colorado).
In each of the last 6 years, El Paso County has had a rate of suicide nearly double the national average.
In the most recent study of large cities in the US (done in 2004), the Colorado Springs suicide rate ranked as the
second highest in the nation, with a rate of 22.25 per 100,000 population. In 5 of the 9 years since that study
(2008, 2009, 2010, 2012, 2013) El Paso County has had even higher rates than in 2004 and even more total
suicides than the year (2004) when they placed second nationally.
The state of Colorado had the 9th highest suicide rate (17.8 per 100,000 population) among all states in the US
in 2011 (the last year for which US data are available) which was 40% higher than the national rate of 12.7. The
state of Colorado broke its state record with 1,053 completed suicides in 2012 (rate of 20.3). By comparison, the
suicide rate in El Paso County in 2012 was 23.4 per 100,000 population, which was 16% higher than the
record breaking rate for the state of Colorado.
El Paso County had more completed suicides than any other county in the state of Colorado from 1999-2013
(1,679). The rate of hospitalizations for injuries resulting from suicide attempts in El Paso County was 18%
higher than the state of Colorado (66.8 vs. 56.4).
The population of 80% of the state of Colorado lives in 9 counties (all with populations of 269,000 or more). Of
those 9 counties, El Paso County has the highest rate of suicide (23.3) from 2008-2013.
El Paso County had 30% more suicides from 2008-2013 (878) than the next largest amounts in counties of
comparable size (Jefferson County had 622 suicides; Denver County had 601; Arapahoe County had 582).
El Paso County is the worst county in one of the worst states in the US for the issue of suicide.
The rates of suicide in El Paso County are grossly elevated, as compared to state and national rates, in several
specific populations:
El Paso County
Veterans
Older adults
Teenagers
Whites (2000-2005)
Hispanics (2000-2005)
39.3
(100% higher than national rate)
18.9
(48% higher than national rate)
9.2
(65% higher than national rate)
19.2
(63% higher than national rate)
13.1
(101% higher than national rate)
State of
Colorado
41.8
United States
18.1
12.8
8.7
5.5
16.8
11.8
9.4
5.7
19.7
15
Economic Impact on El Paso County
 From 2004-2006 the 296 completed suicides cost El Paso County approximately $143 million per year, or
$1.45 million per suicide.
 The medical costs associated with El Paso County suicides is about $4 million annually, or $3,600 per
completed suicide.
 From 2004-2006, 1,100 hospitalizations for attempted suicide were recorded for El Paso County
residents. The total costs to the county were approximately $9.25 million per year ($5.5 million cost of lost
work, plus $3.75 million in medical costs), or $25,000 per attempt.
Resources Available in El Paso County
 Current suicide-related resources in Colorado are insufficient to meet the needs of state residents.
 More than half of Colorado counties are designated by the federal government as “manpower shortage areas”
for psychiatrists and other mental health professionals.
 Colorado’s per capita expenditures for mental health care are well below most states ($74 compared to
national average of $100).
Sources of Statistics
 Suicide Rates by State (American Association of Suicidology)
 Suicide in Colorado (The Colorado Trust – 2002 and 2008)
 Suicide Deaths in Colorado by County (Colorado Department Of Public Health and Environment, Death
Statistics)
 Suicide in El Paso County (A report done in 2009 by Rhonda D. Terry Ph.D. and Annette D. Fryman, RN,
MBA - sponsored by Pikes Peak Behavioral Health and Suicide Prevention Partnership)
16
Military and Suicide
Matt Reid, Chief Deputy, El Paso County Coroner’s Office
August 8, 2014

El Paso County Coroner’s Office (EPCCO) does NOT have jurisdiction over Ft. Carson. “It is like another state
or country.”
 EPCCO DOES have jurisdiction over the USAFA, Peterson, Schreiver, and even parts of NORAD.
 Active Duty Military who die in El Paso County fall under the jurisdiction of EPCCO.
 Suicide is now the leading cause of death among active-duty soldiers.
 Ft. Carson officials refuse to release details of suicide cases.
 Ft. Carson appears on track to tie or surpass the number of suicides its soldiers committed in 2013, according to
statistics provided by the post. (The Gazette; Oct. 22, 2012)
 Ft. Carson officials say they’ve implemented programs to get counseling for those who need it and to teach
others to watch for warning signs.
 “The issue comes down to choice”, said Maj. Chuck Weber, the post’s Chief of Behavioral Health. “We all
have choices,” Weber said. “Those choices are what you’re going to do and the things that are going to happen.
What you picked out. Why’d you pick that pen? I don’t know all those answers. That’s why there are so many
feeder programs. We’re going to get them the help.”’
(http://articles.springsmilitarylife.com/articles/fort-996-carson-post.html)
 Suicide rates in the military were the highest among people divorced or separated – with a rate of 19 per
100,000 population; 24% higher than troops who are single
 When researcher asked 72 soldiers at Ft. Carson why they tried to kill themselves, out of 33 reasons they had to
choose from, all of the soldiers included one in particular – a desire to end intense emotional distress.
 The study also found that the soldiers often listed many reasons – an average of 10 each – for suicide,
illustrating the complexity of the problem. Other common reasons included the urge to end chronic sadness, a
means of escaping people, or a way to express desperation. (National Center for Veteran’ Studies)
 There are more than 425,000 US Armed Services veterans living in Colorado, with about 22% of these
veterans having served during the Gulf War period (1990 or later).
 There are no data about the rate of death by suicide among discharged members of the US Armed Services in
Colorado, but there is national evidence that points to the higher risk for suicide among veterans.
 A recently published national study of males based on survey data from 1986-94 found that over time veterans
in the general population were twice as likely to die by suicide as non-veterans, regardless of whether they
sought care with the Department of Veterans Affairs. (Department of Veterans’ Affairs)
*********************************************************************************************
From: El Paso County Suicide Rates: Cause For Alarm?
Rhonda D. Terry Ph.D. & Annette D. Fryman, RN, MBA
May 20, 2009






A portion of the excess suicide rate in El Paso County may be due to the high proportion of veterans in the
population.
Veterans comprise approximately 18% of the Colorado Springs adult population (more than any county
in Colorado), second among metropolitan areas only to Virginia Beach, VA.
The suicide rate for veterans in El Paso County is 39.3; the national rate for veterans is 19.7.
From 2004-2007 veterans accounted for almost one-third of the total suicides in El Paso County (31.1%),
compared to one-fourth (23.3%) in Colorado
In El Paso County and in Colorado, rates are higher among younger and older veterans, compared with middleaged veterans
For the 65 and older age group, veterans accounted for over two-thirds of the suicide deaths in El Paso County
17
24 hour crisis hotline services
(Provided by Rocky Mountain Crisis Partners)
[formerly "Metro Crisis Services"]












Launched in August 2014
State-wide operation with headquarters in Denver
Provides the state of Colorado's 24/7 crisis hotline, 1-844-493-TALK (8255), for any
mental health and substance abuse issue.
Provides a free Program Services Directory.
Provides peer specialists (people who are living with a mental illness or experienced a mental
health crisis themselves and are in recovery)
Provides immediate triage, safety planning, support, consultation and assistance to anyone in
the community who may need it - individuals, families, friends, treatment providers, law
enforcement and first responders.
Every call to the crisis hotline is answered by a mental health professional. No
answering machines, no robot menus, no screening by a receptionist, no scrambling to find a
counselor who happens to be between sessions, no "call us in the morning," no out-of-state
answering services.
Every caller gets immediate, expert, crisis care.
Every one of the Crisis Clinicians has a master’s degree or a doctoral degree. Many of them
have professional licenses from the State of Colorado. Peer Specialists have all completed
specialist training and received a minimum of 80 hours of training.
Crisis Counselors and Peer Specialists are trained in various mental health and substance
issues, have knowledge on and direct relationships with local resources, engage in immediate
problem solving, and make follow up calls to ensure continued care.
State of Colorado is divided into four regions:
o Southeast (Alamosa, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer,
El Paso, Fremont, Huerfano, Kiowa, Lake, Las Animas, Mineral, Otero, Park,
Prowers, Pueblo, Rio Grande, Saguache, Teller)
o Denver Metro (Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver,
Douglas, Gilpin, Jefferson)
o Northeast (Cheyenne, Elbert, Kit Carson, Larimer, Lincoln, Logan, Morgan, Phillips,
Sedgwick, Washington, Weld, Yuma)
o Western Slope (Archuleta, Delta, Dolores, Eagle, Garfield, Grand, Gunnison,
Hinsdale, Jackson, La Plata, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio
Blanco, Routt, San Juan, San Miguel, Summit )
Regional Coordinators will identify, incorporate, and foster relationships with community
resources that serve special populations such as rural residents, cultural and linguistically
diverse groups, individuals, with disabilities, and children, adolescents, and older adults.
24/7 Crisis Hotline for Military/Veterans
Call 1-800-273-TALK (8255), then press 1.
(operated by the American Association of Suicidology)
18
Working on Crisis Hotlines
Ackerman, D. (1997). A slender thread: Rediscovering hope at the heart of crisis. New York, NY: Vintage Books.
First call of the evening. A single father phones about his 16 year old daughter, who has become too wild
for him to manage. She stays out late, even on school nights, drinking heavily with her friends and taking drugs.
Last night she returned home with a black eye and refuses to say how it happened. Seeing her physically hurt is
more than her father can bear, and so he has phoned. We speak for an hour or so, during which he unfolds his deep
frustration, fear, and then anger, and guilt. When he feels calm enough to make plans, we discuss his perhaps joining
a group like Al-Anon. There he would find other people who have loved ones abusing alcohol or other drugs. I
cannot help his daughter, who did not call. The father is suffering; my job is to try to help him.
Although I suggested Al-Anon, I did little talking through the hour-long call. Crisis line counselors are not
therapists. We also don’t engage the caller in the usual give and take of a conversation, or offer advice. What we do
is listen. Sometimes it feels like auditory braille, and I can see the callers’ faces in my mind’s eye, and read their
expressions. Sometimes it works like echolocation: I send out small reconnoitering sounds - a leading question,
perhaps - and wait to hear in what shape and from where it echoes back. There is an art to making listening noises,
which I have not yet mastered, and after a long silence, a caller may ask “Are you still there?” “Yes,” I answer, “I
was just thinking about what you said.”
We do not listen passively, the way one does during a lecture. We’re not much distracted by personal
thoughts, as one is in normal conversation - listening while thinking about what to say next, perhaps something
about one’s own related experiences. We listen actively, and it is physically exhausting. It feels like a contact sport.
Listening athletically, with one’s whole attention, one hears the words, the sighs, the sniffling, the loud
exhalations, the one-beat-longer-than-normal pause before a difficult of tabu word, the voice-falls of misgiving, the
whittling of worry, the many diphthongs of grief, the heavy-tongue of drunkenness, the piled ingots of guilt, the
quiet screeching of self-blame, the breathlessness of fear, the restless volcano of panic, the fumings of stifled rage,
the staccato spasms of frustration, the side-stepping anger of the “Yes, but”-ters, the tumbling ideas of the
developmentally disabled, the magic dramas of the hallucinator, the idea shards of the psychotic, the harrowed tones
of the battered, the bleak deadpan of the hopeless, the pacing of the ambivalent, the entrenched gloom of depression,
the distant recesses of loneliness, the anxiousness that is like a wringing of the hands.
One hears the silences and the spaces between the words, as well. They have a rhythm and shape all their
own. And one hears many inanimate things, too - ice tingling in a glass, a cigarette being smoked, the television set
on in a nearby room, the traffic outside the caller’s window.
Perhaps it seems a little odd to be touching other lives, and analyzing their condition, simply through
sound. But listening in this way is what many animals do, communicating over long distances. Just as doctors
auscultate by pressing their ear to the patient’s chest, or listen down the line of a stethoscope, we press an ear to the
warm receiver of the phone and listen for the heartbeat beneath the words. The words are the surface of an ocean of
grief, and they may sound like a squall, a doldrum, a typhoon; we listen for hidden currents below.
9:15 PM. A middle aged woman calls. She is restless and on edge; her speech sounds a little slurred,
perhaps from drinking. She has phoned often before, and I recognize her voice. The last time I talked with Melissa,
two weeks ago, it was early morning and she was savagely depressed. I have been worried about her for quite a
while because she seems terribly fragile, and I’m afraid we may lose her. In her early 40’s, she is intelligent and
articulate. She has two young children and is in a second marriage, this time to an alcoholic husband who sometimes
becomes violent. She has a poor relationship with her parents. She is going back to school to finish a college degree.
She is breathtakingly sensitive, very critical of herself, pummeled by self-doubt, and often lonely. Her life is riddled
with stress, and it’s only when something hits unbearable proportions that she phones. After all, we are a “crisis”
service. But crisis is a relative term. Everyone’s emotional thermostat is set differently.
By definition, a crisis is what impedes the normal flow of someone’s life, and that may be as public as a
divorce, as physical as an overdose, or as subtle as a nagging worry. We think of crisis as something gone awry, as
an illness of circumstance or fate. Yet, watching wild animals, we see lives storied with crises. For them, crisis is
part of the usual fabric of their lives. It is not rare or special. Although they seek to avoid crises, many more will
arrive. For humans, crisis is also normal, but painful. A “Crisis Service” is “unnatural”. As unnatural as living in a
heated house in winter, and wanting to help others stay warm, too.
When people call in crisis, I want to help them regain equilibrium. There was a time when extended
families played this role - kin and neighbors, peers and elders - offering solace and understanding in times of
19
trouble. With so many generations and in-laws on hand, one could always find a confidant or an advocate. Families
expected crises to emerge from time to time. In evolutionary terms, it provides turning points, it allows necessary
change. Habit is the great deadener; but habit also assures an organism that what worked before will work again. It
is the best survival technique.
I cannot stop the crisis Melissa finds herself in when she calls. All I can offer her is a breather, a temporary
safety zone in which to explore her feelings, and review her resources and options. I can be with her in the long
corridors of the night, when troubles take on monstrous proportions. I can be with her in the morning, when she
phones from a bed she is unable to climb out of, because her day is an avalanche waiting to fall. I can be with her at
noon in a phone booth, just after she has been laid off from work in mid-winter, with no job on the horizon and a
family to help feed. I can be with her when her husband has stormed out to go drinking, and she is shaking in the
aftermath of his violent rage. I can be with her when she gets an F on an exam and decides death is preferable to her
disappointing future. All I can do is be with her telephonically. I listen. At times, I have urged her to call one of the
agencies in town that provide support groups, legal advice, and ongoing help. On rare occasions, when I believed
she was in physical danger from herself or someone else, I intervened and sent help. But my goal is to make
intervention unnecessary because I’ve helped her reach a safer place - mentally or physically. My goal is for her to
keep control of as much of her life as possible. I do not give advice, and sometimes I actually say that.
“I don’t know what to do,” Melissa sobs tonight. Her husband came home drunk and beat her in front of
her small children. She is terrified to stay with him, and terrified he’ll find her if she leaves. In any case, she has no
money of her own, no full time job, no way to feed the children. She is afraid he might even get custody if she runs
off and isn’t employed. “What should I do?” With all my heart, I want to tell her: Leave him! Take the children and
get out now! Now before he comes back home. Get out as fast as you can! But I would not have been the first person
to give her such advice.
“I can’t tell you what to do,” I say, “but maybe together we can figure something out. Let’s explore what
your options are tonight.” Then we review several plans that have occurred to her, and some that occur to me. In
time, still frightened but a little more focused, she decides at least to talk with someone at the Task Force for
Battered Women, who have a safe house where she and her children can go while they help her put her life back
together.
10:30 PM. I hear the front door open, the stairs begin creaking. Soon a woman with short red hair appears
in the doorway to start the next shift. There are 75 counselors on active duty. We have very little in common when it
comes to background, education, family life, religious upbringing, personality or income. Many of us have
experienced great trauma or hardship, survived it , and want to help others. Each of us knows pain, heartache,
humiliation, shock, fury, the unspeakable. Who doesn’t? One might imagine that crisis line counselors lead less
troubled lives than the callers, but that isn’t always true. This was a surprising and powerful discovery for me.
One only has to be able to put one’s own problems on hold and listen heartfully, nonjudgementally, and
focus entirely on someone else’s need. In fact, there is a relief that comes from being able to get your mind off your
problems, while doing work that’s worthwhile. Many big hearted people are drawn to public service of a more
visible sort.
But the crisis hotline attracts people who prefer altruistic anonymity, who don’t want to be singled out.
Being a crisis line counselor may be one of the most emotionally demanding things that human beings do for one
another, but ours is always a private drama, a vicarious relief, an inner triumph.
Suicide hasn’t touched the lives of all crisis counselors, some of whom volunteer for other reasons, but
enough have felt death’s heavy hand on their shoulder to recognize the feeling. If it doesn’t kill you, surviving your
own death or someone else’s can be a tonic, a metallic drug that makes the world shine brighter, your heart beat
stronger, and the knowledge that you can face down death a formidable tool. Almost everything dangerous or
poignant that can happen to human beings has prompted a call to the crisis line during a year. Suicide, murder,
addiction and overdose, sexual or physical abuse, depression, domestic squabbles, confusion about sexual identity,
flashbacks from war, the ordeals of being in prison, student pressures, poverty isolation, insanity, child custody
battles, dire loneliness, various states of grief, and all the trials uncertainties, and conflicts of love. It’s like sitting in
a chair in the middle of a war zone. Hundreds of crisis lines receive calls from millions of people every year. Callers
confide the most intimate details of their lives, the most desperate moments, the most shameful acts. And counselors
listen to their stories, validate their pain, and try to help them survive with grace - or just survive. Most of these
events happen without the townspeople noticing, while babies are being born, gardens are being planted, people
cursing or blessing their bosses, and every family’s Joan or John speaking a first word or packing for college.
20
Key crisis intervention principles
in working with suicidal patients
 Take time to understand what’s going on
 Provide undivided attention
 Listen carefully and strive to form an
empathic bond
 During the process of listening and forming a
bond, assess risk and protective factors
 Focus interventions on process over content
 System management
 Chart documentation / risk management
21
When Morrie was with you, he was really with you.
He looked you straight in the eye, and he listened as if
you were the only person in the world.
“I believe in being fully present.” Morrie said. “That
means you should be with the person you’re with. When
I’m talking to you now, Mitch, I try to keep focused only
on what is going on between us. I am not thinking about
something we said last week. I am not thinking of what’s
coming up this Friday. I am not thinking about doing
another Koppel show, or about what medications I’m
taking.
“I am talking to you. I am thinking about you.”
I remembered how he used to teach this idea in the
Group Process class back at Brandeis. I had scoffed back
then, thinking this was hardly a lesson plan for a
university course. Learning to pay attention? How
important could that be? I now know it is more important
than almost everything they taught us in college.
Albom, M. (1997). Tuesdays with Morrie. New York, NY: Random House.
22
“You have to be steady and
quiet inside. You have to have a
foundation of belief in the
absolute value and beauty of
life. You can’t get too caught up
in it all. You step back, get as
much of the picture as possible,
and you play it moment to
moment.”
Dass, R. & Gorman, P. (1985). How can I help?: Stories and reflections on service. New York, NY: Alfred A.
Knopf, Inc.
23
Counseling Principles Condensed
1. What to do:
a) Listen very carefully (with the 3rd ear).
b) Do the best you can to try to feel what the client is going through - be fully
present.
c) Do the best you can to try to communicate back to the client that you
understand (via reflection of feelings that you hear).
2. Emphasis is not initially on problem solving - it's on being with your client.
3. Need nothing from your client. The stance you want is one of no personal
investment in the outcome of the call. Work toward developing a secondary,
professional ego, one that can delay gratification and needs no gratification from
the client.
4. Sequence:
a) Empathy
b) Information gathering
c) Problem solving
5. If empathic bond is established, it’s a good contact – even if you never got to
phases of information gathering or problem solving.
6. Be in control without being controlling.
7. You don't have to answer a question just because someone asked one.
8. If you find yourself asking a lot of "Have you tried this?" "Have you tried that?"
questions, you're probably getting yourself tied up in knots. If you're lost or
stuck, reflect the last feeling you heard.
9. If you’re lost or stuck, reflect the last feeling you heard.
10. Learn the therapeutic value of limits / boundaries / saying no.
11. Don't try to do too much.
12. Don't try so hard.
13. If nothing seems to be "working", stop trying.
14. Develop inner quietness. Learn to be centered.
15. Develop self awareness, especially awareness of your own needs, vulnerabilities,
sensitivities.
16. Don't be afraid of silence.
17. Be clear with your client about what your role is (and isn't). Be your client’s
counselor, not their friend.
18. Don't ignore, avoid, minimize, make fun of, get angry, judge, impose your own
views, tell the client what to do, impose guilt, make promises you can't keep, try
to trick clients, lie to clients, or say you understand if you don't.
24
25
What A Suicidal Person May Feel Or Experience
Can't stop the pain
Can't feel anything
Can't get rid of the voices that tell me to kill myself
Can't think clearly
Can't make decisions
Can't see a way out
Can't stop feelings of hopelessness
Can't see a future without pain
Can't see myself as worthwhile
Can't sleep, eat, or work
Can't get someone's attention
Can't seem to get control
Can't cope with overwhelming anxiety
Can't imagine living without [whatever may have been lost]
Can't live with the loneliness/isolation
Can't live "like this" (whatever "this" is)
26
Adolescent Suicide
Scope of the problem
 2nd leading cause of death for young people ages 15-19 in Colorado
 5 times more adolescent males than females complete suicide; females are 4 times
more likely to make nonfatal attempts; gender difference lies in the methods used –
majority of both genders use guns to complete suicide, but the majority of nonfatal
attempts consist of overdoses, 80% of which are done by females
 As many as 2 million teenagers may make nonfatal attempts at some point in their
teenage lives
The nature of suicidal impulses in adolescents
 Temporal - specific to a point in time
 Transient
 Situation specific
 Most adolescents who kill themselves give some form of prior warning
 Most suicidal acts by youth are impulsive and unplanned
Challenges unique to adolescents
 Often feel out of control
 Are developmentally caught between childhood and adulthood
 Feel conflict about separating from parents while simultaneously seeking protection
from them
 Due to limited life experience, they tend to be more focused on the present and may
have a limited view of future possibilities
 Limited capacity for delayed gratification
 Highly vulnerable to peer influence
 Often eager to imitate role models as they seek to develop their own identity
Assessing psychological intent in adolescents
 What does the option of suicide mean to the youth
 Motive among young people is often interpersonal and instrumental
 Intended goals of suicidal youth include:
o Escape the pain
o Escape helplessness or hopelessness
o Escape the emotions and thoughts associated with the suicidal state
Assessing suicide plan
 Presence or absence of a plan
 Inquire directly about a plan
 How lethal is the plan
27
 Is the plan carefully thought through
 Are lethal means available to carry out the plan
 High or low rescue-ability
Assessing risk
 Hopelessness is one of the best indicators of suicide risk
 Young people are very sensitive to interpersonal pressures and expectations of
others (parents, siblings, peers, coaches, teachers, girlfriends, boyfriends)
 Suicidal youth often experience blows to self-esteem, sense of self, and ability to
cope
 Suicidal youth often have problems with peers, and are less likely to have a close
confidant
 Parents of suicidal adolescents often have conflictual relationships, including threats
of separation / divorce
 Adolescent suicides are often linked to a significant precipitating event,
particularly an acute disciplinary crisis or a rejection or humiliation
Clinical Considerations
 Essential for a clinician to be empathic and to connect to the youth’s subjective
experience of pain
 Young people experience psychological pain especially intensely
 Explore possible options and alternative ways of coping
 Evaluate negative and positive forces in the youth’s life
 Ask directly about the pressures being experienced
 Ask specifically about the youth’s perceived “fit” with his or her family
Suicide Risk in Juvenile Justice System and Foster Care
 The risk of suicide is increased when a young person becomes involved in the
juvenile justice or child welfare systems
 The majority of suicide attempts are made within the first 24 hours of entering a
facility or foster home
 Other high risk times include:
o after being arrested
o sentencing
o entering a new facility or home
o probation revocation
28
Continuum of Negative Thought Patterns
Levels of increasing suicidal intention
Content of voice statements
Thoughts that lead to low self-esteem or inwardness (self-defeating thoughts)
1. Self-depreciating thoughts of everyday life.
You’re incompetent, stupid. You’re not very
attractive. You’re going to make a fool of yourself.
2. Thoughts rationalizing self-denial. Thoughts
discouraging the person from engaging in
pleasurable activities.
You’re too young (old) and inexperienced to apply
for this job. You’re too shy to make any new friends,
or, Why go on this trip? It’ll be such a hassle. You’ll
save money by staying home.
3. Cynical attitudes toward others, leading to
alienation and distancing.
Why go out with her (him)? She’s cold, unreliable;
she’ll reject you. She wouldn’t go out with you any
way. You can’t trust men (women).
4. Thoughts influencing isolation; rationalizations
for time alone, but using time to become more
negative toward oneself.
Just be by yourself. You’re miserable company any
way. Who’d want to be with you? Just stay in the
background, out of view.
5. Self-contempt; vicious self-abusive thoughts and
accusations (accompanied by intense angry affect).
You idiot! You bitch! You creep! You stupid shit!
You don’t deserve anything. You’re worthless.
Thoughts that support the cycle of addiction(s)
6. Thoughts urging use of substances or food followed
by self-criticisms (weakens inhibitions against
self-destructive actions, while increasing guilt and
self-recrimination following acting out).
It’s okay to use drugs; you’ll be more relaxed. Go
ahead and have a drink; you deserve it. (Later) You
weak-willed jerk! You’re nothing but a drugged out
drunken freak.
Thoughts that lead to suicide (self-annihilating thoughts)
7. Thoughts contributing to a sense of helplessness,
urging withdrawal or removal of oneself from the
lives of people closest.
See how bad you make your family/friends feel.
They’d be better off without you. It’s the only decent
thing to do – just stay away and stop bothering them.
8. Thoughts influencing a person to give up priorities
and favored activities (points of identity).
What’s the use? Your work doesn’t matter any more.
Why bother even trying? Nothing matters any more.
9. Injunctions to inflict self-harm at an action level;
intense rage against the self.
Why don’t you just drive across the center divider?
10. Thoughts planning details of suicide (calm, rational,
often obsessive, indicating complete loss of feeling
for the self).
You have to get hold of some pills, then go to a hotel,
etc.
11. Injunctions to carry out suicide plans; thoughts
baiting the person to commit suicide (extreme
negative thought constriction).
You’ve thought about it long enough. Just get it over
with. It’s the only way out!
The Glendon Association (1996)
29
The Three Key Components of Completed Suicide
Thomas Joiner Ph.D.
Department of Psychology – Florida State University
From: Why People Die By Suicide (2005)
Key Questions
 How exactly does one acquire the ability to enact suicide?
 What are the constituents of the desire for suicide?
Three Key Components of Completed Suicide
1) Acquired capability to enact lethal self-injury
2) Perceived burdensomeness
3) Thwarted belongingness
1st Key Component: The acquired capability to enact lethal self-injury
Accrues with repeated and escalating experiences involving pain and provocation, such as:
 Past suicidal behavior
 Repeated injuries
 Repeated witnessing of pain, violence, or injury
 Any repeated exposure to pain and provocation
With repeated exposure, one habituates:
 Serves to squelch the powerful instinct to live
 The “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated
with self-harm
 Second, and relatedly, opponent processes may be involved:
o Opponent process theory (Solomon, 1980) predicts that, with repetition, the effects of a provocative
stimulus diminish, and the opposite effect, or opponent process, becomes amplified and
strengthened.
o The opponent process for suicidal people may be that they become more competent and
courageous, and may even experience increasing reinforcement, with repeated practice at suicidal
behavior.






2nd Key Component: Perceived Burdensomeness
Feeling ineffective to the degree that others are burdened is among the strongest sources of all for the desire to
die by suicide.
3rd Key Component: Thwarted Belongingness
The need to belong to valued groups or relationships is a powerful, fundamental, and extremely pervasive
human motivation. When this need is thwarted, numerous negative effects on health, adjustment, and well-being
have been documented.
This need is so powerful that, when satisfied, it can prevent suicide even when perceived burdensomeness and
the acquired ability to enact lethal self-injury are in place. By the same token, when the need is thwarted, risk
for suicide is increased. The thwarting of this fundamental need is powerful enough to contribute to the desire
for death.
This perspective is similar to the classic work of Durkheim (1897), who proposed that suicide results, in part,
from failure of social integration.
Prevention/Treatment Implications
The model’s logic is that prevention of “acquired ability” OR of “burdensomeness” OR of “thwarted
belongingness” will prevent serious suicidality.
Belongingness may be the most malleable (capable of being shaped or formed or influenced).
30
Through
therapy
perception
can change
Therapy is
especially
helpful here
Perceived
burdensomeness
Thwarted
belongingness
Those who are
capable of
suicide
Serious
attempt,
or death
by
suicide
Once this
occurs it is
very
difficult to
get rid of
31
Can suicidal thinking be addictive?
Tullis, Ken (1998). A theory of suicide addiction. Sexual Addiction &
Compulsivity: The Journal of Treatment and Prevention, 5 (4),
311-324.
 Some patients appear to be "hooked" on suicidal fantasies and
behaviors.
 Very first suicidal thought is important:
o "I don't have to kill myself right now, but the idea to do so is
mine"
o "When I had this thought, I found my drug, my own fort, my
own secret. It gave me a fix. It calmed me down."
 Tons of people are having suicidal thoughts and not telling anyone.
Characteristics of addiction as they apply to suicide
1. Onset in childhood
2. Mood alteration - the critical element; distinguishes suicide
addiction from other patterns of suicide and from a compulsion
3. Secrecy
4. Fantasies
5. Tolerance
6. Suicidal pre-occupation
7. Rituals
8. Multiple suicide attempts
9. Trance
10. Withdrawal
Suicide Anonymous: www.suicideanonymous.net
32
Indicators of Lethality
1. Age and sex
Men are more lethal than women (3.6 male deaths by suicide for each female death by suicide). Increasing
age is associated with increasing lethality. Older men are in general most lethal and young women least.
*********************************************************************************************
2. Symptoms and Behaviors
Sleep disturbance
Anger or rage
Helpless / hopeless
Thought disordered
____
____
____
_*__
Intoxication
Social withdrawal
Poor social support
Extreme anxiety ____
_*__
_*__
____
Appetite change ____
Confusion
Shame or guilt
____
____
*********************************************************************************************
3. Stressors / Situational Factors
Threatened or actual loss:
Death ____
Status ____ Employment ____
Life events:
Accidents____
Legal problems____
Changes in home / work environment____
Childbirth / abortion____
Health ____
Relationship ____
Intense family discord____
Change in status____
*********************************************************************************************
4. History of Suicidal Behavior
One or more high lethality attempts
One or more low lethality attempts
Family member attempted / succeeded
Repeated threats or ideation
No previous history
_*__
_*__
_*__
____
____
*********************************************************************************************
5. Suicidal plan
None____
Vague____
Specific (when, how, where)_*__
(when is particularly critical here)
*********************************************************************************************
6. Means and availability
Not available____
Obtainable____ Readily available_*__ In hand_*__
OTC Drugs____ Cutting wrists____
Prescription drugs____
Auto_*__
Carbon monoxide____
Hanging_*__
Explosives_*__ Firearm_*__
Jumping_*__
*********************************************************************************************
7. Location
Near others (likely to be discovered)____
Isolated_*__
*********************************************************************************************
8. Resources
No friends_*__ Available but unwilling_*__ Living with someone____ Close relationships____
33
Suicide Risk Assessment
This contact is from:
 the suicidal person themselves
 someone concerned about a suicidal person (check boxes below that apply to the suicidal person in
question)
Primary Risk Factors (High risk if ANY ONE factor is present - consider seeking consultation)













Recent suicide attempt (last 6 months) with lethal method (firearms, hanging, strangulation, jumping from high places, or
any other lethal method).
Recent suicide attempt (last 6 months) resulting in moderate to severe wound or harm.
Recent suicide attempt (last 6 months) with low rescue-ability (no known communication regarding the attempt, discovery
unlikely because of chosen location and timing, no one nearby or in contact, active precaution to prevent discovery)
Recent suicide attempt (last 6 months) with subsequent expressed regret that it was not completed AND continued
expressed desire to commit suicide.
Stated intent to commit suicide imminently.
Stated intent to commit suicide with a lethal method selected and readily available.
Stated intent to commit suicide AND preparations made for death (writing a will or a suicide note, giving away
possessions, making certain business or insurance arrangements).
Stated intent to commit suicide with time and place planned AND foreseeable opportunity to commit suicide.
Stated intent to commit suicide without ambivalence OR with inability to see alternatives to suicide.
Stated intent to commit suicide with current active psychosis.
Stated intent to commit suicide with major affective disorder, schizophrenia, or recent alcohol abuse.
Stated intent to commit suicide during the week after hospital admission or the month immediately after discharge.
Presence of acute command hallucinations to kill self whether or not there is expressed intent.
Secondary Risk Factors (Consider seeking consultation if SIX OR MORE factors are present)
The following factors all significantly contribute to suicide risk but are of a less critical nature.










Recent separation or divorce
 Rigidity (difficulty adapting to life changes)
Recent death of significant other
 History of sexual abuse
Recent loss of job or severe financial setback  Pattern of failures in previous therapy
Other significant loss/stress/life changes
 Conflict/confusion over sexual orientation
Social isolation/poor social supports
 More than one psychiatric hospitalization.
Current or past chemical dependency/abuse
 Expressed hopelessness
Persistent long-standing insomnia
 History of family suicide (or recent suicide by close friend)
History of suicide attempt(s) or aborted attempts without actual harm
Current or past difficulties with impulse control or antisocial behavior
Significant depression, especially accompanied by guilt, worthlessness or helplessness
Major Contributing Demographic Factors




Male
Single, divorced, separated or widowed
Living alone
Elderly



Unemployed
Chronic financial difficulties
Major medical problems
Assessment of Risk - Use your clinical judgment to rate the level of risk (check only one)



High Risk (risk factors are severe; suicidal person needs to be contained to ensure safety)
Moderate Risk (suicidal person has enough risk factors with enough severity to merit special precautions including
supervisory review)
Low Risk (suicidal person can be treated in a community setting; risk factors do not suggest imminent risk)
Comments_______________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
34
Assessment questions to address
 Ask about habituation, burdensomeness, belongingness (Joiner)
Assess specific risk factors
 Is there a wish to die?
 Is there a plan?
 What is the method planned?
 What risk factors are present?
 Is there a history of recent substance abuse?
 What medical illnesses are present?
 What psychiatric diagnoses are present?
 Is there a past or family history of suicide attempts?
 Is there a history of impulsivity?
 Has there been a will made recently?
 Is there a history of recent losses, and how do they relate to past
history of losses?
 Is there talk of plans for the future?
 What is the nature of the caller’s social support system?
Also assess presence of protective factors
 Effective clinical care for mental, physical and substance use
disorders
 Easy access to a variety of clinical interventions and support for help
seeking
 Restricted access to highly lethal means of suicide
 Strong connections to family and community support
 Support through ongoing medical and mental health care relationships
 Skills in problem solving, conflict resolution and nonviolent handling
of disputes
 Cultural and religious beliefs that discourage suicide and support self
preservation
Source: Suicide Prevention Resource Center (SPRC)
35
36
Suicide Safety Contracts







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No evidence that suicide safety contracts work
Of those who used no-suicide contracts, over 40% report that they had patients die by suicide
or make a near-lethal attempt while under contract
They only tell patients what not to do and neglect telling patients what they should do
Contracts can lead to inattention; not good to rely on
Contracts assume person is competent
Usually motivated by fear of litigation (caregiver’s stress vs. patient’s)
Overvalued; seduces false security
May distract from careful assessment
Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
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Area of disagreement among clinicians
There is no “correct “ answer on this issue. The only thing that makes any person’s opinion “correct”
is whether it turns out to be effective in preventing a suicide.
My beliefs:
o I believe that the most sustaining thing one can do for a person who is suicidal is to provide
that person with an empathic experience. Included in that is an emphasis on undivided
attention, listening very carefully, and the quality of presence.
o Also included in that, from my point of view, is the clinician (or friend or family member)
taking a position of not needing anything from the client, when the client is in those desperate
moments.
o I encourage people who are doing crisis intervention with suicidal people to work on a stance
of needing nothing from the client, no personal investment in the outcome of the clinical
interaction – in other words, work on developing a secondary, professional ego that can delay
gratification and does not need gratification from the client. My concern in using a suicide
contract is that it has the potential to be experienced by the suicidal person as
something that person needs to do FOR the clinician, to help cover the clinician’s ass, if
you will, thus shifting the perhaps-already-brittle attention away from the client’s
overwhelming emotions and needs. If the suicidal person did experience it that way, I
fear that the empathic bond could be damaged, and thus the essential sustaining
element could be at risk.
o In the eyes of many, contracts are made to be broken. Just because one signs a contract does
not mean that person will adhere to that contract. So it can represent a false sense of security,
which can be dangerous in suicide work.
o On the other hand, if you have a suicidal client that you know well, and you know that the
client is the kind of person who will keep his or her contracts, I do recommend using
them, but only in those specific cases.
o I think agencies tend to like suicide contracts, mostly because of the fear of potential
litigation, but I question their overall usefulness as an actual preventer of a suicide.
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Chart Documentation and Risk Management
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If it isn’t written down, it didn’t happen
“Certain people are out to get us. These people are called “lawyers” and the reason they are out
to get us is simple: they are paid to do so” (Gutheil, 1980)
“Using paranoia as a guiding reality principle is a sound basis for effective record-keeping”
(Bongar, 2002)
“Even the soundest decision may appear dubious in hindsight” (Gutheil, 1990)
In a study of patients at higher risk for suicide (i.e. with a diagnosis of Major Depressive Disorder),
clinicians failed to document adequately the presence of a lifetime history of suicide attempt” in:
o 24% of cases on admission; and
o 28% of cases in the discharge summary (Malone, Szanto, Corbitt, & Mann, 1995)
A patient’s chart should reflect:
o assessment of risk
o high risk factors present in current situation and in patient’s background
o low-risk factors present
o sources of information consulted
o factors influencing clinical decisions regarding actions taken or not taken and how those factors
were balanced in a risk-benefit analysis (Bongar, 1992; Packman & Harris, 1998)
Consultation
 Affords the opportunity to obtain a “biopsy of the standard of care” (Appelbaum & Gutheil, 1991)
 Only 27% of clinicians routinely seek consultation to assist in their assessment of suicide (Jobes,
Eyman, & Yufit, 1990)
 Lack of clear, professional guidelines regarding confidentiality and informed consent in this area
 Most common is “informal peer or peer group consultation”
 A formalized consulting relationship involving payment and a writen, durable record is
preferable
 “Suicide prevention is not best done as a solo practice” (Schneidman, 1981)
Risk Management Guidelines
 Be familiar with current literature on risk factors, management of the suicidal patient, and current
developments in the field (Packman & Harris, 1998)
 Take complete patient history, including indicators of suicide risk that are based on diagnostic criteria
and known risk factors.
 Obtain all previous medical and mental health records as well as releases to consult with past
caregiver(s).
 Be able to use DSM-IV diagnostic criteria to accurately diagnose and to guide treatment.
 Recognize personal limitations, understand own proficiencies and be aware of one’s emotional
tolerance for working with suicidal patients.
 Good record keeping.
 Routinely seek consultation from professional peers with expertise in treating suicidal patients.
 Consult with legal counsel to determine if insurance carrier needs to be notified of attempted or
completed suicide.